Lives could be saved by specialist heart failure teams

Hospitals in England should ensure that a specialist heart failure team is on hand to see people who are acutely unwell as a result of suspected heart failure – a change that could save many lives.

This is according to new guidance issued by NICE, which as well as assessing new drugs, also issues guidance on how specific diseases and conditions should be treated.

Heart failure is the number one reason for hospital admission in people 65 or over, but NICE says there is great variation across the country in how these patients are treated.

“Acute heart failure accounts for over 67,000 hospital admissions in England and Wales each year and is the leading cause of hospital admission in people 65 years or older. It is usually caused because the heart muscle has become too weak or stiff to pump enough blood to meet all the needs of the body” says Professor Mark Baker, Director of the Centre for Clinical Practice at NICE.

“Acute heart failure is life-threatening so it’s important to diagnose the problem correctly so patients get the best treatment.”

People with acute heart failure are usually admitted through a hospital’s accident and emergency department. Those who are very sick tend to be admitted to intensive care units, high dependency units or the coronary care units.

The remaining patients go into either the general medical wards or to the cardiology wards, depending on what treatment they need. NICE says this practice is not standardised across hospitals and different factors affect the decision, including the person’s age, whether they have any other illnesses and where the available beds are.

“The treatment patients with acute heart failure receive, and how successful that treatment is, varies depending on the unit they are admitted to” says Professor Jonathan Mant, Chair of the Guideline Development Group.

“Patients admitted to hospital with acute heart failure should have early and continued input from a specialist heart failure team. In addition, immediate access to natriuretic peptide testing (which assesses the levels of stress the heart is under), timely access to echocardiography to show how well the heart is working, and use of proven drug therapies are important components of care which if used optimally will reduce death and ill health associated with this condition.”

In the UK, the most common cause of heart failure is coronary artery disease, with many patients having suffered a heart attack in the past. Symptoms and signs of heart failure include breathlessness, fatigue and fluid retention.

Unlike chronic heart failure, which is more common and which develops slowly over time and worsens gradually, acute heart failure develops suddenly. This can either happen following a heart attack that has caused damage to an area of the heart or, more commonly, because the body can no longer compensate for chronic heart failure (acute decompensated heart failure).

Recommendations on drug treatment

The guidance also covers what drugs should be used and when. NICE say once stabilised, persons presenting with acute heart failure who are already taking beta-blockers should continue the treatment unless they have a heart rate less than 50 beats per minute, second or third degree atrioventricular block, or shock.

• Start or restart beta-blocker treatment during hospital admission in people with acute heart failure due to left ventricular systolic dysfunction, once their condition has been stabilised – for example, when intravenous diuretics are no longer needed.

• Ensure that the person’s condition is stable for typically 48 hours after starting or restarting beta-blockers and before discharging from hospital.

• Offer an angiotensin-converting enzyme inhibitor (or an angiotensin receptor blocker if there are intolerable side effects) and an aldosterone antagonist during hospital admission to people with acute heart failure and reduced left ventricular ejection fraction. If the angiotensin-converting enzyme inhibitor (or angiotensin receptor blocker) is not tolerated an aldosterone antagonist should still be offered.

Diagnosis and chronic heart failure treatment

As well as the role of specialist management units the guideline considers the role of echocardiography and early blood tests (natriuretic peptide testing) to diagnose acute heart failure, the use of breathing support, and drug treatments for acute heart failure. The guideline also addresses treatment after acute heart failure has been stabilised, including surgery, and starting drug treatments that are used in the management of chronic heart failure.

Acute heart failure drugs in the pipeline

Despite there being a huge unmet medical need in acute heart failure, as well as chronic heart failure, there have been few new treatments launched in recent years. Novartis look set to change that in chronic heart failure, with their new treatment, LCZ696, which has been hailed as a potential breakthrough for patients with the condition.

However another Novartis drug for acute heart failure – Serelaxin (RLX030) – was roundly rejected by an FDA advisory committee earlier this year. Serelaxin (RLX030) is a novel treatment and was granted Breakthrough Therapy designation status by the FDA in June 2013 because of its potential to treat heart failure. But the committee was unconvinced by the drug’s data, and Novartis will have to pursue further trials in order to prove its value to patients.

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